Participate in Liver Research
Explore clinical research studies in Columbus Ohio for people with Liver Disease.
Complete this short survey to see if you qualify
Please tell us about yourself so that we can find suitable study locations near you. All the information you complete will remain private.
First Name
Last Name
Email
Primary Phone
Mobile Phone
Address
Apt. / Ste.
City
Zip Code
We need this information calculate your body mass index (BMI).
Height (Feet)
Height (Inches)
Weight (lbs)
Date of Birth
Gender
Male
Female
Other
Please choose the race and/or ethnicity that describes yourself. Choose all that apply:
Hispanic or Latino
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Prefer not to say
Have you been diagnosed with, or suspected to have liver disease?
Yes
No
Do you have any of the following health conditions?
Cancer in the last 5 years
Poorly controlled diabetes (i.e., not on any treatment)
Allergies to medications such as opioids, NSAIDS, etc
Cardiac Disease (e.g., myocardial infarction, seizures, stroke, etc.)
Kidney Disease
Respiratory disease (such as COPD, history of P.E., etc.)
History of HIV, Hepatitis B, or Hepatitis C
How did you hear about us?
Your privacy is important to us. Please confirm that you have reviewed our
Privacy Policy
and agree to the Terms of Use.
Yes, I have reviewed the privacy policy and agree to terms of use
Send
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